SIU Investigator - Remote

The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies.

Responsibilities

• Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder

• Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information

• Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process

• Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures

• Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations

• Other duties as assigned

Minimum Qualifications

• Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required

• 2 years of work experience in investigation, audit, healthcare or legal

Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy

• Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions

• Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders

• Ability to distill complex concepts or situations into concise and compelling communications

• Knowledge and understanding of pharmacy and medical claims processing environment

Preferred Qualifications

• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)

• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)

• Licensed Practical Nurse (LPN) or Registered Nurse (RN)

• Experience working with RxClaims and/or JUDI

• Previous audit and investigation experience

• Pharmacy background within retail, mail order, hospital, or compounding setting

• Data mining experience

• Excel experience